(Annexure-A)

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APPLICATION FOR THE POST OF FACULTY RSETI ON CONTRACT BASIS

To,
The Zonal Manager,
C/o Dena Rural Development Foundation (DRDF)
Dena Bank, Zonal Office
2nd Floor, LIC Investment Building II
Behind LIC Divisional Office
Jeevan Bima Marg,Pandri
Raipur (C.G) 492004 (Chhattisgarh)

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Paste Passport size

Photograph
Please sign across
the Photograph

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With reference to your advertisement on Banks website dated _______________ I, submit my

application in prescribed format.
1. NAME (in full):

______________________________

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2. ADDRESS FOR CORRESPONDENCE:

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_____________________________________
_____________________________________

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_____________________________________

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_____________________________________
_____________________________________

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3. CATEGORY: _______________
4. If person with Disability:
Type of disability:
Percentage of disability:

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5. DATE OF BIRTH (As per School leaving Certificate):

Age in completed years as on 01.01.2015

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6. Details of Non refundable Application Fee:

___________

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Mode of payment: - NEFT / Fee payment challan Branch/ Branch Name:

Transaction ID/ UTR No.

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Date of Payment:
7. Contact Details:

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MOBILE NO. E-MAIL ID-

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Amount:

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LANDLINE No.

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8. GENDER:

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9. NATIONALITY:
10. RELIGION:
11. MARITAL STATUS:

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12. Fathers/ HUSBANDS NAME:

13. PERMANENT ADDRESS:
_____________________________________

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_____________________________________

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_____________________________________
14. EDUCATION QUALIFICATION

Details
Board/
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Qualification

(B.A./B.Sc/
M.A./M.Sc etc.)

University

Graduation

Year of Subject
Marks
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Full time/
Part Time

Passing

/
Speciali
zation

(Rank if
any)

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Post
Graduation
Professional
Qualification
Others/
Computer
Knowledge

15. RELATIVE EXPEREINCE - Total (in years) ________________

SN

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Name of Bank

Designation Duration

Responsibilities

Pay
Scale

From To
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Extra Ordinary
Achievements

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16. RETIRED ON VRS/ SUPERANNUATION

______________________
DATE OF RETIREMENT
______________________
TOTAL YEARS OF SERVICE
_________years
OUT OF WHICH AS AN OFFICER
__________years
NO. OF YEARS WORKED AS RURAL BRANCH MANAGER ________years

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17. DATE OF ISSUE OF SERVICE

CERTIFICATE OF PREVIOUS EMPLOYER

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___________

18. DETAILS OF PRESENT EMPLOYMENT:

(a) Organisation
(b) Full Address:
(c) Position:
(d) Reporting to:
(e) Salary/Compensation presently drawn:

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19. Brief detail of experience in the Bank in respect of working in Rural area /as Rural

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Development Incharge/ as Faculty/as LDM etc.

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20. Significant Achievement (If Any) in respect of above assignments-

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21. Name and addresses of two references1) ___________________________________________

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___________________________________________

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___________________________________________

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___________________________________________

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2) ___________________________________________

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___________________________________________

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___________________________________________
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DECLARATION

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I hereby declare that the particulars furnished above are true and correct to the best of
knowledge and belief and I understand that in the event of any information being found
false or incorrect at any stage or not satisfying the eligibility criteria according to the
requirements of the relative advertisement, my candidature/ appointment for the said post
is liable to be cancelled/terminated at any stage and if appointed, my service are liable to
be terminated. I am willing to serve anywhere in India. I agree that Bank has right to transfer
me to any part of the country at its discretion.

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I hereby agree that any legal proceedings in respect of any matter of claims or disputes
arising out of this application and/or out of said advertisement can be instituted by me only
at Mumbai and Courts/tribunals/forums at Mumbai undertake to abide by all the terms and
conditions mentioned in the advertisement displayed on Banks website dated_________.

Place: _______________

(Signature of Applicant)

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Date: ____________

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Enclosures:
1.
2.

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3.

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